The General Surgery Coding Coach 2008 Archives

Is Injection of Sentinal Node Reportable?

Question:

Our surgeon performed a sleeve gastrectomy for obesity and we received a denial from Medicare.  Is this correct?

Answer:

Yes.  According to Medicare policy, the following procedures are typically considered non-covered services for the treatment of morbid obesity: 

• Laparoscopic vertical banded gastroplasty
• Open sleeve gastrectomy
• Laparoscopic sleeve gastrectomy
• Open adjustable gastric banding

Question:

Our surgeon just brought us an operative note where he removed 10 polyps in the colon by snare technique.  He wants to know if he can report this with a 10 in the units box.

Answer: 

No, the CPT Code 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique by definition includes one polyp or multiple polyps.  Thus CPT code 45385 may only be reported one time. 

Percutaneous Jejunostomy

Question:

Our surgeon documented the placement of a percutaneous jejunostomy.

Is there a CPT code to use for this procedure?

Answer:

The surgeon would report CPT Code 49441 Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.  This code includes fluoroscopic guidance so the 77xxx codes would not be reported in addition to CPT code 49441.  By definition, the surgeon must have a digital or paper image of the fluoroscopic guidance and must dictate a separate interpretation of the fluoroscopic guidance. 

Infected Mesh

Question:

Our surgeon took the patient back to the OR during the global period for the removal of infected mesh. Is there a CPT code to report this procedure?

Answer:

Report CPT Code 11008 in addition to the surgical procedure performed.  CPT code 11008 Removal of prosthetic material or mesh, abdominal wall for infection (e.g., for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure) was revised in 2008 to include a reference to infected mesh that may be removed following a hernia repair.    

Diagnosis Code for Conversion to Open Procedures

Question:

We were at a seminar and the instructor was talking about a V code to use when the surgeon converts a laparoscopic procedure to an open.  We did not know such a code existed.  Can you help us find the code?

Answer:

The appropriate diagnosis code is V64.41 Laparoscopic surgical procedure converted to open procedure.   Report the appropriate diagnosis codes for the surgical procedure as the primary diagnosis and the V code as the last diagnosis linked to the surgical procedure. 

Question:

How do we code a laparoscopic inquinal hernia repair that the surgeon had to convert to an open because of Intraoperative complications?  

Answer:

The surgeon reports the appropriate open inguinal hernia CPT code.  If the documentation supports significant work over and above the normal open procedure, the surgeon may append modifier 22 to the open CPT code. 

Question:

We recently began receiving rejections from Medicare because we did not have an entry in Box 11 on the CMS 1500 claim form.  Medicare is telling us we must put NONE in the box if there is no primary Insurance.  This has never happened before.

Answer:

We researched this question and found the following instructions in the Medicare Manual.  The Medicare instructions state that if the patient does not have any primary insurance to Medicare, the word “none” must be entered in box 11.  Here is the excerpt form the Claims Submission Instruction section related to the question.

Item 11 -THIS ITEM MUST BE COMPLETED, IT IS A REQUIRED FIELD. BY COMPLETING THIS ITEM, THE PHYSICIAN/SUPPLIER ACKNOWLEDGES HAVING MADE A GOOD FAITH EFFORT TO DETERMINE WHETHER MEDICARE IS THE PRIMARY OR SECONDARY PAYER. If there is insurance primary to Medicare, enter the insured's policy or group number and proceed to items 11a - 11c. Items 4, 6, and 7 must also be completed. NOTE: Enter the appropriate information in item 11c if insurance primary to Medicare is indicated in item 11. If there is no insurance primary to Medicare, enter the word “NONE” and proceed to item 12.

We believe that although the policy existed before, it was not enforced as zealously as CMS wanted.  Your recent denials are likely due to this fact.